MSK History
 

Joint Pain

 
 
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Overview

  • Pain affecting the hands, wrists, spine, knees or other joints may herald inflammatory or non-inflammatory arthropathy. By assessing certain characteristics of the pain it is possible to distinguish between these two broad groups and focus in on the cause of a patient's symptoms.

Aetiology

    • Causes of Joint Pain

    • Inflammatory

    • Rheumatoid arthritis
    • Seronegative spondyloarthropathies - reactive arthritis, ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease-related arthritis
    • Crystal arthropathies - gout, pseudogout
    • Vasculitis - Wegener’s, polyarteritis nodosa, giant cell arteritis
    • Systemic inflammation - SLE, polymyositis, dermatomyositis
    • Septic arthritis - gonococcal, Staph, Strep, gram negative
    • Other infection - TB, Lyme disease
    • Sarcoidosis
    • Degenerative

    • Osteoarthritis
    • Traumatic

    • Fracture
    • Dislocation
    • Soft tissue injury - menisceal tear, ligamentous tear
    • Haemarthrosis (traumatic or in the setting of coagulopathy)
    • Other

    • Malignancy - sarcoma, metastasis
    • Avascular necrosis
    • Tendonitis
    • Bursitis

History of Presenting Complaint

    • Site

      Number of joints affected; whether the pain is symmetrical or asymmetrical; whether large or small joints are affected.
    • Monoarthralgia: one joint affectedNon-specific; most causes can (initially) present with monoarthralgia
    • Polyarthralgia: multiple joints affectedMore likely to represent an inflammatory cause
    • Symmetrical small-joint involvementSuggestive of rheumatoid arthritis
    • Affecting large joints of the lower limbSuggestive of osteoarthritis or reactive arthritis
    • Pain, swelling and warmth in the great toeClassical presentation of acute gout
    • Onset

      Whether the pain began suddenly or gradually, and in what situation.
    • Sudden onset knee pain and swellingSuggestive of haemarthrosis
    • Onset post traumaSuggestive of fracture, dislocation or soft tissue injury
    • Onset post recent infectionSuggestive of reactive arthritis
    • Character

    • Burning or ‘electric’ painSuggestive of neuropathic pain or fibromyalgia
    • Deep, constant aching painRed flag for malignancy
    • Radiation

      Whether the pain moves anywhere else.
    • Back pain radiating down the arm or legSuggestive of neuropathic pain
    • Associated Symptoms

      Whether the pain is associated with any other symptoms.
    • Joint swellingNon-specific, may be suggestive of inflammation
    • Numbness / paraesthesiaSuggestive of nerve pain
    • FeversSuggestive of septic arthritis or inflammatory cause
    • Eye pain / conjunctivitisSuggestive of reactive arthritis
    • DysuriaSuggestive of reactive arthritis
    • Dry eyes / mouthSuggestive of Sjögren’s syndrome
    • RashPotential SLE or psoriatic arthritis
    • Back pain with bladder or bowel symptomsRed flag for cauda equina syndrome
    • Timing

      How long the pain has been going on for, and whether it is worse at any specific time of day.
    • Constant pain that does not improveRed flag for malignancy
    • Acute attacks of painSuggestive of acute gout
    • Exacerbating Factors

      Whether there is anything that makes the pain worse, such as exercise or prolonged rest.
    • Present at restSuggestive of inflammatory cause
    • Exacerbated with activitySuggestive of non-inflammatory cause e.g. osteoarthritis
    • Back pain worse walking downhillSuggestive of neuropathic pain
    • Alleviating Factors

      Whether there is anything that relieves the pain.
    • Improved with activitySuggestive of inflammatory cause
    • Back pain improved walking uphillSuggestive of neuropathic pain
    • Severity

      How bad the pain is on a scale of 1-10 with 10 being the worst pain, and how the pain is functionally affecting the patient.
    • Hand - buttons, keys, taps, shopping bags, dressing, showering, eating
    • Wrist - dressing, toilet, eating
    • Elbow -  dressing, lifting objects
    • Shoulder - dressing, top shelves, hanging washing, lifting objects
    • Back -  walking, shoes, stairs, hills, lifting
    • Hip - walking, getting in/out of cars, stairs
    • Knee - chairs, shoes, stairs, kneeling, getting in/out of cars
    • Ankle - walking
 
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 Baker DG, Schumacher Jr HR. Acute monoarthritis. New England Journal of Medicine. 1993 Sep 30;329(14):1013-20.
Bengtsson AA, Rylander L, Hagmar L, Nived O, Sturfelt G. Risk factors for developing systemic lupus erythematosus: a case–control study in southern Sweden. Rheumatology. 2002 May 1;41(5):563-71.
Cooper GS, Dooley MA, Treadwell EL, St Clair EW, Gilkeson GS. Risk factors for development of systemic lupus erythematosus: allergies, infections, and family history. Journal of clinical epidemiology. 2002 Oct 1;55(10):982-9.
Dacre JE, Worrall JG. The rheumatological history. Medicine. 2010 Mar 31;38(3):129-32.
de l’Escalopier N, Anract P, Biau D. Surgical treatments for osteoarthritis. Annals of physical and rehabilitation medicine. 2016 Jun 1;59(3):227-33.
Fransen M, Nairn L, Winstanley J, Lam P, Edmonds J. Physical activity for osteoarthritis management: a randomized controlled clinical trial evaluating hydrotherapy or Tai Chi classes. Arthritis Care & Research. 2007 Apr 15;57(3):407-14.
Heidari B. Knee osteoarthritis prevalence, risk factors, pathogenesis and features: Part I. Caspian journal of internal medicine. 2011;2(2):205.
Herrick A. Diagnosis and management of scleroderma peripheral vascular disease. Rheumatic Disease Clinics of North America. 2008 Feb 1;34(1):89-114.
Hummers LK, Wigley FM. Management of Raynaud's phenomenon and digital ischemic lesions in scleroderma. Rheumatic diseases clinics of North America. 2003 May;29(2):293-313.
Hunzelmann N, Scharffetter KK, Hager C, Krieg T. Management of localized scleroderma. InSeminars in cutaneous medicine and surgery 1998 Mar (Vol. 17, No. 1, pp. 34-40).
Katz JN, Earp BE, Gomoll AH. Surgical management of osteoarthritis. Arthritis care & research. 2010 Sep;62(9):1220-8.
 Majithia V, Geraci SA. Rheumatoid arthritis: diagnosis and management. The American journal of medicine. 2007 Nov 30;120(11):936-9.
McInnes IB, Schett G. The pathogenesis of rheumatoid arthritis. New England Journal of Medicine. 2011 Dec 8;365(23):2205-19.
Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM. A systematic review of recommendations and guidelines for the management of osteoarthritis: the chronic osteoarthritis management initiative of the US bone and joint initiative. InSeminars in arthritis and rheumatism 2014 Jun 1 (Vol. 43, No. 6, pp. 701-712). WB Saunders.
Puttick MP. Rheumatology: 11. Evaluation of the patient with pain all over. Cmaj. 2001 Jan 23;164(2):223-7.
Sallam H, McNearney TA, Chen JZ. Systematic review: pathophysiology and management of gastrointestinal dysmotility in systemic sclerosis (scleroderma). Alimentary pharmacology & therapeutics. 2006 Mar;23(6):691-712.
Shah AA, Wigley FM. My approach to the treatment of scleroderma. InMayo Clinic Proceedings 2013 Apr 1 (Vol. 88, No. 4, pp. 377-393). Elsevier.
Smolen JS, Landewé R, Bijlsma J, Burmester G, Chatzidionysiou K, Dougados M, Nam J, Ramiro S, Voshaar M, Van Vollenhoven R, Aletaha D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Annals of the rheumatic diseases. 2017 Jun 1;76(6):960-77.
Squance ML, Reeves GE, Bridgman H. The lived experience of lupus flares: features, triggers, and management in an Australian female cohort. International journal of chronic diseases. 2014;2014.
Turesson C, O’fallon WM, Crowson CS, Gabriel SE, Matteson EL. Extra-articular disease manifestations in rheumatoid arthritis: incidence trends and risk factors over 46 years. Annals of the rheumatic diseases. 2003 Aug 1;62(8):722-7.
Vasoo S. Drug-induced lupus: an update. Lupus. 2006 Nov;15(11):757-61.
Young A, Koduri G. Extra-articular manifestations and complications of rheumatoid arthritis. Best practice & research Clinical rheumatology. 2007 Oct 1;21(5):907-27.
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